1 / 82

Acute Cardio-renal Syndrome.

Acute Cardio-renal Syndrome. 台大醫院雲林分院 黃道民 Tao-Min Huang NTUH Yun-Lin Branch taominhuang@gmail.com. A clinical scenario. A 62-year-old man PHx : DM, type 2 CKD, stage III ICMP, NYHA Fc II CC : 1 week of progressive dyspnea and weight gain. PE : BP: 118/70mmHg; HR = 82 bpm

lynn
Download Presentation

Acute Cardio-renal Syndrome.

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Acute Cardio-renal Syndrome. 台大醫院雲林分院 黃道民 Tao-Min Huang NTUH Yun-Lin Branch taominhuang@gmail.com

  2. A clinical scenario. • A 62-year-old man • PHx: • DM, type 2 • CKD, stage III • ICMP, NYHA Fc II • CC:1 week of progressive dyspnea and weight gain. • PE: • BP: 118/70mmHg; HR = 82 bpm • Basilar rales • Bilateral pitting edema.

  3. A clinical scenario. • ECG: NSR • N-Terminal pro-BNP = 16,500 pg/mL (0-450 pg/mL) • CK, CK-MB, Tr. I: WNL • UN = 38mg/dL; Cre= 2.0mg/dL • (Baseline 1.7-1.8mg/dL) • U/A, renal sonography: unremarkable • CXR

  4. Chest film.

  5. Treatment. • IV bolus Furosemide 20mg q6h • U/o = 500ml/day • Continous Furosemide • U/O = 300ml/day • Cre = 2.2mg/dL • Spironolactone and lisinopril were held. • U/O = 100ml/day • Orthopnea aggravated. • Nephrologist consultation for RRT

  6. A Common scenario in Critical Care.

  7. Epidemiology

  8. Severity of WRF. Gottlieb et al., J Card Fail. 2002;8(3):136

  9. How to define WRF Gottlieb et al., J Card Fail. 2002;8(3):136

  10. Worsening Renal Function 1. WRF: defined with ≥0.3mg/dL elevation of SCr. 2. 1004 patients admitted to hospital. Forman et al. J Am CollCardiol. 2004;43(1):61

  11. Mid-Term Survival Am Heart J. 2005 Aug;150(2):330

  12. Adjusted HR for ESRD: 147,007 AMI Elderly. Arch Intern Med. 2008 May 12;168(9):987

  13. Adjusted HR for All Cause Death: 147,007 AMI Elderly. Arch Intern Med. 2008 May 12;168(9):987

  14. Cox’ Proportional Survival Function: 147,007 AMI Elderly Arch Intern Med. 2008 May 12;168(9):987

  15. WRF: a meta-analysis All Cause Mortality HR = 1.62 J Card Fail. 2007 Oct;13(8):599

  16. J Card Fail. 2007 Oct;13(8):599

  17. WRF in ADHF • Incidence: 19-45% • Negative outcome predictor in: • Short- and long-term all-cause and cardiovascular mortality • Prolonged duration of hospitalization • Increased readmission rates • Accelerated progression to ESRD • Higher healthcare costs Eur Heart J. 2010 Mar;31(6):703

  18. Pathophysiology. Adequacy of arterial filling and renal perfusion Degree of venous congestion Raised intra-abdominal pressure.

  19. Pathophysiology: Low cardiac output. Heart 2010;96:255

  20. Not all CRS are equal. J Am CollCardiol. 2006 Jan 3;47(1):76

  21. Mortality between preserved/reduced Renal Function. O.R. = 2.45 (Diastolic) vs. 2.72 (Systolic) J Am CollCardiol. 2006 Jan 3;47(1):76

  22. Congestion and WRF: not novel findings J Physiol. 1931 Jun 6;72(1):49

  23. CVP is better predictive. J Am CollCardiol2009;53:589

  24. Which is more important? Congestion or WRF? (-) WRF (+) Congestion (+) WRF (+) Congestion (+) WRF (-) Congestion (-) WRF (-) Congestion 1 year Death or reTx. Circ Heart Fail. 2012 Jan 1;5(1):54

  25. Which is more important? Congestion or WRF? (-) WRF (+) Congestion (+) WRF (+) Congestion (+) WRF (-) Congestion (-) WRF (-) Congestion 1 year Death, HF readmission, or reTx. Circ Heart Fail. 2012 Jan 1;5(1):54

  26. Intra-Abdominal Pressure David J.J. Muckart, MD, University of Natal Medical School

  27. IAP and Mortality Crit Care Med 2005; 33:315

  28. IAP and Mortality Crit Care Med 2005; 33:315

  29. IAP and Change of Cre. J Am CollCardiol. 2008 Jan 22;51(3):300

  30. Congestion? Kidney Injury? • WRF (or CRS type 1) is bad. • Congestion (high filling pressure, fluid overload) is bad. • But WRF is not associated with (so much) hazard, after adjustment of “Congestion.”

  31. De-congestive therapy.

  32. Diuretics • Patients admitted with evidence of significant fluid overload should initially be treated with loop diuretics, usually given intravenously. • Early intervention has been associated with better outcomes for patients hospitalized with decompensated HF. ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009;119(14):1977

  33. Diuretics and BNP: AEHERE registry 58,465 ADHF episodes. J Am CollCardiol. 2008 Aug 12;52(7):534

  34. Factors predicting in-hospital death:Early Diuretics is Important. J Am CollCardiol. 2008 Aug 12;52(7):534

  35. Sub-clinical fluid retention. Adamson et al. J Am CollCardiol. 2003;41(4):565

  36. Sub-clinical fluid retention. Adamson et al. J Am CollCardiol. 2003;41(4):565

  37. Benefit of De-congestion therapy. • Symptom improvement • Cardiopulmonary function • Myocardial structure • Re-hospitalization rates Am J Kidney Dis. 2011;58(6):1005

  38. Loop Diuretics:Continuous or Intermittent? J Am CollCardiol. 1996 Aug;28(2):376

  39. Loop Diuretics:Continuous or Intermittent? J Am CollCardiol. 1996 Aug;28(2):376

  40. Loop Diuretics: Cont. or Bolus? 24hrs’ urine Cochrane Database Syst Rev. 2005:20;(3):CD003178.

  41. Loop Diuretics: Cont. or Bolus? All Cause Mortality Cochrane Database Syst Rev. 2005:20;(3):CD003178.

  42. Loop Diuretics: Cont. or Bolus? Significant e- change Cochrane Database Syst Rev. 2005:20;(3):CD003178.

  43. Loop Diuretics: Cont. or Bolus? Hearing Loss Cochrane Database Syst Rev. 2005:20;(3):CD003178.

  44. Loop Diuretics: Cont. or Bolus? Increased SCr. Cochrane Database Syst Rev. 2005:20;(3):CD003178.

  45. How to Prescribe Diuretics in ADHF: DOSE Study • Dose: • High dose: total daily intravenous furosemide dose 2.5 times their total daily oral loop diuretic dose in furosemide equivalents • Standard Dose:total intravenous furosemide dose equal to their total daily oral loop diuretic dose in furosemide equivalents • Route: • BolusEvery 12 hours.(Q12H) • Continuous Randomized to 4 groups (1:1:1:1) Felkeret a. N Engl J Med. 2011;364(9):797

  46. Loop Diuretics: Dose? Continuous?Global VAS Score Felkeret a. N Engl J Med. 2011;364(9):797

  47. Loop Diuretics: Dose? Continuous?Composite Outcomes Felkeret a. N Engl J Med. 2011;364(9):797

  48. Complications: DOSE Felkeret a. N Engl J Med. 2011;364(9):797

  49. Limitations of DOSE. • Primary endpoint: Global assessment of symptoms. • Underpowered to detect other clinical outcomes. • In addition, • bolus group tended to receive a higher total dose • Supine position may promote diuresis Felkeret a. N Engl J Med. 2011;364(9):797

  50. Diuretics Resistance • When diuresis is inadequate to relieve congestion, as evidenced by clinical evaluation, the diuretic regimen should be intensified using either: • Higher doses of loop diuretics; • Addition of a second diuretic (such as metolazone, spironolactone or intravenous chlorothiazide); or • Continuous infusion of a loop diuretic. (Level of Evidence: C) ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009;119(14):1977

More Related